Summary & Overview
CPT 69602: Revision to Modified Radical Mastoidectomy
CPT code 69602 represents a surgical revision converting a prior simple or complete mastoidectomy into a modified radical mastoidectomy. It is used when a previous mastoidectomy fails to achieve a dry ear, leading to recurrent otitis media with purulence, eardrum perforation, and persistent or recurrent hearing loss. The code captures a definitive operative intervention aimed at removing residual infected mastoid air cells and granulation tissue and reconstructing the ear canal when necessary.
This publication addresses national implications for otologic surgery coding and payment. Key payers covered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find clinical context for when the code is applicable, typical sites of service, and the procedural elements that define the service. The report outlines billing considerations and common modifiers (input provided), and highlights areas where documentation should support the revision nature of the procedure and failure of prior mastoidectomy.
Intended for clinicians, billing professionals, and policy analysts, the summary provides benchmarks and policy-relevant insights into coding use and payer coverage patterns. Data not available in the input for some comparative benchmarks and associated taxonomies is noted.
Billing Code Overview
CPT code 69602 describes a revision of a prior mastoidectomy to a modified radical mastoidectomy. The procedure involves removal of all mastoid air cells, excision of granulation and infected tissue, and resection of bony partitions of the mastoid cavity. The surgeon also reconstructs the ear canal as needed. This operation is performed when an earlier simple or complete mastoidectomy failed to produce a dry ear, resulting in recurrent otitis media with pus accumulation, possible tympanic membrane perforation, and recurrent or residual hearing loss.
Service type: Surgical revision of previous mastoidectomy (otologic surgery)
Typical site of service: Hospital operating room or outpatient surgical center (OR/surgical suite)
Clinical & Coding Specifications
Clinical Context
A 52-year-old male with a history of prior mastoid surgery presents with persistent purulent otorrhea, chronic perforation of the tympanic membrane, recurrent otitis media, and progressive conductive hearing loss despite prior tympanomastoid procedures. Imaging (CT temporal bone) demonstrates persistent mastoid air cell disease and residual cholesteatoma with bony partitions and granulation tissue. The otologic surgeon schedules a revision mastoidectomy and plans a modified radical mastoidectomy (69602) to remove remaining mastoid air cells, excise granulation and infected tissue, and reconstruct the external auditory canal as needed to achieve a dry, safe ear.
Preoperative workflow includes history/physical, audiometry, CT temporal bones, informed consent documenting prior failed mastoidectomy and indication for revision, pre-op anesthesia evaluation, and coding as 69602 for the surgical service. Typical intraoperative documentation includes indication for revision, findings (residual disease, adhesions, ossicular status), extent of mastoidectomy performed, canal reconstruction details, and estimated blood loss. Postoperative workflow includes short-term inpatient or ambulatory recovery depending on ASA status, wound care instructions, audiology follow-up, and documentation of any complications or additional services (e.g., ossicular reconstruction staged later). Typical payors for coverage reviews include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.
Coding Specifications
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